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Unlisted Face or Jaw Prosthesis Service

New Hampshire rates for HCPCS 21089

Covers the making or fitting of an artificial replacement for a missing or damaged part of the face, jaw or mouth when no standard named service applies. These custom devices restore appearance and function after cancer surgery, injury, or a condition present from birth. Because each one is built for a single person, the specialist records exactly what was designed and fitted.

Rates data updated July 2026.

Facilitymedian $1,549 · 10th–90th $1,349$4,3650%20%10th90th$1,549Professionalmedian $1,047 · 10th–90th $1,047$1,0470%50%100%$1,047$1.0K$2.0K$5.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$1,288.25
Median
$1,412.54
Typical High
$2,630.27
Cigna
Setting
Professional
Modifier
Global
Typical Low
$1,047.13
Median
$1,047.13
Typical High
$1,047.13
Harvard Pilgrim
Setting
Facility
Modifier
Global
Typical Low
$7,413.10
Median
$7,413.10
Typical High
$7,413.10
United
Setting
Facility
Modifier
Global
Typical Low
$7,413.10
Median
$7,413.10
Typical High
$7,413.10
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$2,511.89
Median
$3,801.89
Typical High
$4,897.79